Impact van dementie op de motoriek. evaluatie en aangrijpingspunten voor preventie en revalidatie. Ivan Bautmans. Frailty in Ageing research group
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1 Impact van dementie op de motoriek evaluatie en aangrijpingspunten voor preventie en revalidatie. Ivan Bautmans Frailty in Ageing research group Dementia Subcortical Parkinson, Huntington Cortical Alzheimer Vasculair Mixed 2
2 Stages of dementia Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 Phase 7 Global Deterioration Scale (GDS) Subjectively and objectively normal Subjective complaints, objectively normal Mild Cognitive Impairment Early dementia Moderate dementia Moderately severe dementia Severe dementia 3 4
3 26-46% less risk for cognitive decline in subjects aged >64yrs compared to passive lifestyle Sofi ea J Intern Med 2011; 269: N=1449, age years, mean follow-up= 21 yrs Leisure-time physical activity at midlife 2x/week =reduced risk of dementia (-52%) AD (-62%) Rovio ea Lancet Neurol
4 Underlying mechanisms blood flow to the brain risk for cerebro-vascular & cardiovascular diseases/events Neurotrophic effect Release of Brain Derived Neurotrophic Factor (BDNF) neuronal growth & survival stress = cortisol levels Sofi ea J Intern Med 2011; 269: Motor changes accompanying cognitive decline
5 Subcortical versus Cortical Subcortical Dementia Begin Phase apparant motor signs: tremor, chorea increased tonus, abnormal gait bradykinesia Cortical Dementia Begin Phase Motor signs are hidden more cognitive signs End Phase fetal posture, rigidity, contractures End Phase fetal posture, rigidity, contractures 9 40 elderly presenting increased fall-risk (aged 80.6±5.4 yrs) 41 old controls (aged 79.1±4.9 yrs) Accelerometer in belt in between SIPS Tri-axial accelerometer, sampling rate 100Hz Bautmans ea Gait & Posture :
6 Mean of 2 walks (18m) Gait Speed (m/s) Step Time symmetry (%) ( step time L R)/ (mean step time L&R) Autocorrelation coefficient Step regularity Stride regularity N= # measurements m= Phase shift in measurements x= acceleration Moe-Nilssen ea. JBiomech 2004 Bautmans ea Gait & Posture :
7 Gillain ea Ann Phys Rehab Med 2009; 52: N=474, MMSE 16/30, followed for 13 years 14 Scarmea ea. Neurology 2004
8 Hobbelen ea. J Geriatric Physical Therapy Hobbelen ea. IntPsychogeriatr
9 Management of motor deficits in elderly with cognitive decline Rehabilitation for older people in long-term care Forster ea Cochrane review 2010, Age&Ageing trials involving 3611 participants overall mean age = 82 yrs (69-89) 30 to 45-minute sessions, 3x per week physical rehabilitation worthwhile and safe, reducing disability, few adverse events no recommendations for best intervention
10 Review of 27 studies on older people (age>70 yrs) in long-term care facilities and nursing homes Evidence-Based guidelines Weening-Dijksterhuis ea. Am J Phys Med Rehabil 2011;90:
11 Evidence-Based guidelines Weening-Dijksterhuis ea. Am J Phys Med Rehabil 2011;90: Evidence-Based guidelines Weening-Dijksterhuis ea. Am J Phys Med Rehabil 2011;90:
12 Exercise & Dementia Thomas & Hageman J Gerontol Med Sci 2003; 58A: MMSE = 17.8 ± 7.2 (mild moderate) 6 weeks strength training (theraband) Feasible 2 à 3 sessions per week older nursing home residents with moderate dementia (age 85 yrs; mean Mini-Mental State Examination 17.7) randomly allocated to walking for 30 min, 5 days a week, for 6 weeks. control = social visits in the same frequency NO SIGNIFICANT EFFECTS ON COGNITION? TOO LOW EXERCISE INTENSITY? 24
13 Systematic review including 16 clinical trials 25 Evidence-Based guidelines Blankevoort ea Dement Geriatr Cogn Disord 2010;30:
14 ES 0.2=small effect; 0.5=medium effect; >0.8=large effect Blankevoort ea Dement Geriatr Cogn Disord 2010;30: Strength training 28 28
15 Functional strength training Endurance training 30 30
16 Passive interventions? Fetal Posture Treatment targeting output countering contractures by means of forced passive mobilization Treatment targeting input Increasing stability and tactile input = PDL 32
17 33 Consequences Institutionalized elderly Dementia >50% Alterations in muscle tonus (paratonia) Changes in posture Dysphagia (bolus<20ml) Van De Rakt 2001, Hobbelen 2004, Ritmeijer e.a. 2001, Ertekin e.a. 2001, Logemann 2000, Goeleven
18 ANTEROPOSITION High cervical: Extension Middle cervical: Flexion Low cervical: Flexion 35 EXTENSION High cervical: Extension Middle cervical: Extension Low cervical: Extension 36
19 Kyphotic High cervical: Flexion Middle cervical: Flexion Low cervical: Flexion 37 Posture - dysphagia Guidelines dysphagia Rehabilitation exercises for strength, coordination, Compensation Posture, volume, taste, consistency HOW? 38
20 39 Aim of the study Correction of head posture by manual mobilizations Feasibility Compliance / refusal / Influence on dysphagia Bolus volume 1ml, 3ml, 5ml, 10ml, 15ml, 20ml 40
21 Participants Eligibility Elderly (>65yrs) nursing home residents (AZ- Damiaan, Tremelo, Belgium, 450 beds) cognitive impairment due to dementia (MMSE<24/30) known dysphagia (logopedist) Exclusion No postural alteration Refusal 41 Methods Enrolled 10 female, 6 male mean age = 85 ± 6 years mean MMSE = 8 ± 6 /30 Randomized controlled trial 1 week (3 sessions) cervical mobilisation Control (socializing visit) Cross-over design Independent therapists Blinded assessors Intention to treat analysis 42
22 43 44
23 Feasibility 90% sessions successfully performed 3 sessions impossible due to patient's hostility 2 sessions impossible due to illness no complications 45 after 1 session from 6 ± 7 ml to 9 ± 7 ml (p=0.01) after 1 week intervention from 6 ± 7 ml to 12 ± 8 ml [+100%] (p=0.03) Improvement of dysphagia limit following cervical mobilization. outlier, *extreme, significant improvement (p<0.05), significant difference in evolution between mobilization and control (p<0.05). 46
24 CONCLUSIONS Physical exercise = counterstone for prevention and management of cognitive decline Motor alterations occur with cognitive disorders hidden in early stage (fall risk!) Worsen with pathologic evolution End stage = fetal posture Physical activity feasible & effective in all stages of dementia Gentle passive mobilizations can be integrated in PDL-strategy 47 Thank you! 48
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